Schizophrenia. Delusional disorder. Schizotypal disorder презентация

DEFINITION
Gr..
φρήν
– mind, reason
Schizophrenia - a progressive endogenous polymorphic mental disorder characterized by dissociation of mental processes, continuous or paroxysmal long course and different expressions of productive (positive) and negative disorders, leading to mental defect in the form of personality changes, invert, emotional and volitional depletion, reduction of energy potential.
σχίζω
– cleave

HISTORY OF SCHIZOPHRENIA
Emil Kraepelin:In 1883, separated schizophrenia (which he called dementia praecox) from bipolar disorder (which he called manic-depressive psychosis) largely on the basis of the clinical course of the syndromes.
"Dementia praecox" 1896
Beginning at puberty
Progressive course
The outcome is a particular type of dementia

HISTORY OF SCHIZOPHRENIA
Eugen Bleuler
"Schizophrenia" (1911)
"Basic symptoms"
Four "A":
Autism
Associate synthesis disorders
Emotional and volitional disorders (Apathy and Ambivalence)

HISTORY OF SCHIZOPHRENIA
Four «A»
E.BIeuler
AUTISM
AMBIVALENCE
APATHY
ABULIA

Epidemiology of schizophrenia
The prevalence of schizophrenia in the world is estimated at between 0.8 - 1%
The incidence is 15 per 100 000 population
The highest incidence is in the age between 20 and 29 years
Male: female ratio is 1: 1

Psychological consequences of schizophrenia
The most debilitating of all mental illnesses
Reduced quality of life for the patients and their relatives
Social "drift" – reduction of the level of patient`s social life
Rarely marry and have children
30% of patients make a suicidal attempt, 10% commit suicide successfully
Occupy more than half of psychiatric hospital beds
75% of patients smoke, 40% abuse alcohol, up to 30% use psychoactive substances
High health care costs for treatment (in the US - $50 billions).

Etiology of schizophrenia
Genetically inhereted
Adverse
impact of the environment
Psychodynamic
Infectious
Autoimmune
Neurotransmitter
«Stress-diathesis»
Hypotheses

Pathogenesis of schizophrenia
Neurotransmitter disorders
Morphological changes
Serotonin theory
The dopamine theory
increase in dopaminergic activity in the mesolimbic pathway
decrease in dopaminergic activity in the mesocortical pathway
pathogenetic mechanisms
atrophy of the prefrontal cortex

Pathogenesis of schizophrenia
2 types of schizophrenia
Crow Т. (1985)
hyper-dopaminergic activity
Hypo dopaminergic activity
Atrophy of gray matter in the prefrontal cortex
POSITIVE
NEGATIVE
good response to classic neuroleptics (D-receptor blockers)
minimal structural damage
relatively satisfactory adaptation
predominance of positive symptoms
atypical antipsychotics are more effective (blocking serotonin receptors more than dopamine receptors)
hidden start
predominance of negative symptoms
chronic or malignant course

CLINIC OF SCHIZOPHRENIA
Emotional disorder
NEGATIVE
SYMPTOMS
(Deficits)
– define nosological diagnosis of schizophrenia
POSITIVE
SYMPTOMS
(productive)
– determine the type of schizopherenia
Violations of will and inclinations
Formal thought disorders
Hallucinations
Delusions
Psychic automatism
CLINICAL PRESENTATION
ONEIROID
Motor-volitional disorders

«SKHIZIS»
The process of thinking is disrupted without connection between thoughts
– "Splitting" is a violation of the integrity of the operation of individual spheres of mental activity and the whole mind of the patient
Emotional processes is characterized by emotional inconsistency, inadequacy, ambivalence
Volitional processes is the loss of a single rod willed person, guided human activity that defines its behavior.
The loss of the boundaries of the personality: the feeling that one's own mental processes is imposed, “is made" by someone from outside (psychic automatism with the syndrome Kandinsky-Clerambault)
Autism is the gap between the inner world of the patient and the outside world

Classification
Types of course
Clinical forms
F20.0 Paranoid schizophrenia
F20.1 Hebephrenic schizophrenia
F20.3 Undifferentiated schizophrenia
F20.4 Post schizophrenic depression
F20.5 / Residual Schizophrenia
F20.6 / simple type of schizophrenia
F20.8 / other type of schizophrenia
F20.9 / Schizophrenia, unspecified
F20.x0 continuous;
F20.x1 episodic with progressive defect;
F20.x2 episodic stable defect;
F20.x3 remitting episodic (recurrent);
F20.x7 other;
F20.x9 observation period less than a year.

A simple form of schizophrenia
There are no positive symptoms
negative symptoms grow rapidly, reaching a degree of schizophrenic defect
The flow is continuous, progressive

A simple form of schizophrenia
(Anorexia due to apathy abulic syndrome)

Hebephrenic schizophrenia
Starting at adolescence, young adulthood
Hebephrenia syndrome dominate (including emotional and volitional and behavioral disorders: silliness, grimacing, disinhibition inclinations, jumps, dancing, inappropriate jokes, foul language, may prove unwarranted aggression). On par with this catatonic inclusions may be present.
Sometimes - occasional hallucinations and individual delusional experiences
The flow is malignant, continuous
Stop of mental development at the age of onset of the disease

hebephrenic schizophrenia (hebephrenic excitation)

Paranoid schizophrenia
Hallucinatory-paranoid syndrome dominates.
Possible transformation syndrome: paranoiac -> paranoid -> paraphrenic
Duration is continuous or paroxysmal
continuously-progressive and attack-like progressive

Paranoid schizophrenia
(Pretentious posture, hallucinatory-paranoid syndrome)

Paranoid schizophrenia
(Paraphrenic syndrome)

Catatonic schizophrenia
It begins with an episode of psychomotor agitation.
Leading syndrome – catatonic
Meets basic criteria for Schizophrenia
At least 2 catatonic symptoms predominate:
Stupor or motor immobility (catalepsy or waxy flexibility)
–Hyperactivity w/o apparent purpose or not influenced by external stimulation
– Mutism or marked negativism
– Peculiar posturing, stereotypes, or mannerisms
– Echolalia, echomimia, echopraxia
variants:
- Lucid (light) catatonia (without impairment of consciousness, has a malignant course)
oneiric catatonia (with polymorphic productive symptoms, relatively mild course)

Catatonic schizophrenia (waxy flexibility)

Catatonic schizophrenia (waxy flexibility, a symptom of the proboscis)

Catatonic schizophrenia

Febrile schizophrenia
oneiric bouts of catatonia, accompanied by a rise in temperature and the emergence of a serious physical disorders
With a significant rise in temperature (more than 40), and the development of trophic disorders represents a threat to the life of patients (!)
Requires differential diagnosis with neuroleptic malignant syndrome
- requires the use of high doses of chlorpromazine and / or electro-convulsive therapy

Schizophrenic "defect"
– irreversible personality changes occur during the course of the disease and combine negative symptoms, residual symptoms of active process and personal qualities of an
individual

Types of schizophrenic "defect"
Apatite-abulic - the most common defect of emotional and volitional spheres (passivity, inactivity, lack of initiative, indifference to their appearance, health, food, living conditions, untidiness, loss of interest to communication, decrease in social status etc.).
Asthenic - negative symptoms include low intelligence,levels of knowledge and skills. While pre-existing skills are preserved, the level of mental activity of the person is reduced, with the signs of psychic asthenia (vulnerability, sensitivity), exhaustion, dependency, self-doubts.
Neurotic - with the background of emotional blunting, the picture is blurred with the prevalence of disorders of thinking and complaints like neurosis.
Psychopathic - sharp negative changes in the emotional and intellectual spheres, anxiety, instability.
Pseudo organic - psychopathic, combined with the slowing of thought and instinct`s disinhibition.

Types of schizophrenic "defect"
Thymopathic - "acquired cyclothymia."
Hyperesthenic - appearance after the attack before unusual traits: punctuality, strict regulation regime, the "correctness" and the hyper-social and other.
Paranoid - most pronounced in the area of disorders of thinking, intelligence stored, negative symptoms expressed moderately. In the structure of the defect - residual delusional and hallucinatory experiences, there is tendency to paranoid ideas, with no emotional color and their tendency to expand and systematize.
Hypomania - a kind of dissociation of psychic functions without adequate emotional response.
Mixed - a combination of different types.

The prognosis for schizophrenia
It depends on the type of disease
The earlier debut, the worse is the prognosis
Prognosis is better if affective symptoms are prevalent in the clinical picture
Prognosis is worse for patients with poor premorbid background
The forecast is worse for the negative schizophrenia than for the positive (by Crow T.)
Prognosis is worse in the absence of criticism to disease and poor compliance (willingness to follow the doctor's prescriptions)
When properly chosen therapy and good social conditions can lead to good social adaptation of patients

Treatment
of SCHIZOPHRENIA

STAGES OF TREATMENT

Treatment
of schizophrenia
Biological methods (insulin-coma therapy, electro-convulsive therapy)
psychopharmacology (Antipsychotics)
psychotherapy

THERAPY
BIOLOGICAL
PSYCHOSOCIAL
Psycho-educational sessions with patients' relatives
Psychotherapy
with patients
Antipsychotics (chlorpromazine, galloperidol, risperon etc.).
detoxication
SYMPTOMATIC
tranquilizers (sibazon, Phenazepamum etc.)
timostabilizatory
(valprokom, carbamazepine)
antidepressants
(amitriptillin, melitor et al.)
Correction of side effects of neuroleptic treatment (extrapyramidal disorders)
-anticholinergics (tsiklodol, neomidantan)
-nonselective β-blockers
pyrogenic
(malyaro-, sulfazintherapy)
PHARMACOTHERAPY
"Shock" (electroconvulsive therapy, atropino- insulincomatose therapy)
NEUROMETABOLIC
(B3, B6, Zn, Mg)

The history of the development
of biological therapy
Pyrogenic therapy - (1918) for the treatment of progressive paralysis (a form of syphilis of the brain), 1924 -sulfozintherapy (in / m 1% sulfur slurry in olive oil) for the treatment of schizophrenia. At the present time not used.
"Shock" methods
insulin-coma therapy,
electro-convulsive therapy
Psychopharmacotherapy - 1952 - First use of antipsychotic (neuroleptic) (chlorpromazine (chlorpromazine)),
1955 - the first use of an antidepressant (imipramine).

Electroshock treatment (EST)
was suggested in 1938
by an Italian psychiatrist U.
Cherletti and a
neurophysiologist L.Bini.
Electrodes are applied to
the patient’s temples, and
electric current with the voltage
of 60-120 V runs through them
during 0.2-0.4 sec. It develops
a seizure similar to a grand mal.
The mechanism of the
medical effect is not clear.
This method proved to be effective in very severe depressions (when antidepressants fail to help), catatonic stupor and acute hypertoxic (febrile) schizophrenia.
EST is also used as a way to overcome therapeutic resistance to psychoactive drugs in chronic mental disorders.

Insulin coma treatment
Consists in giving the patient on an empty stomach some individually selected dose of insulin which causes hypoglycemic coma (or a subcoma state). This state is interrupted by an intravenous injection of glucose. The method was suggested in 1933 by an Austrian psychiatrist M. Zackel. Insulin shocks are caused every day, during 10-40 days.
The period of hypoglycemia may develop fits of convulsions, a collapse-like state, cardiac arrhythmias. Repeated hypoglycemia are possible, especially at night.
It is most indicated for schizophrenia which began not more than a year ago.

First Generation Antipsychotics (Neuroleptics) – typical neuroleptics
Relieve only positive symptoms
Chlorpromazine (Thorazine)
phenothiazines
primarily blocks D1 & D2
Haloperidol (Haldol)
butyrophenones
primarily blocks D2
Triftazin
Flupenthixol + depot form
Zuclopenthixol + depot form

First Generation Antipsychotics (Neuroleptics) – typical neuroleptics
Relieve only positive symptoms
Chlorpromazine (Thorazine)
phenothiazines
primarily blocks D1 & D2
Haloperidol (Haldol)
butyrophenones
primarily blocks D2
Triftazin
Flupenthixol + depot form
Zuclopenthixol + depot form

Major Side Effects
Movement Effects (Extrapyramidal)
Parkinsonism
Akathisia
Tardive Dyskinesia
Agranulocytosis
↓ white blood cells (WBC)
Not frequent, but 50% mortality ~

Second Generation Antipsychotics (Atypical Neuroleptics)
Relieve negative & positive symptoms
Lower risk of Parkinsonism
Akathisia
Tardive Dyskinesia

Clozapine Clozaril
↑ Agranulocytosis
Risperidone Risperdal
↓↓ Agranulocytosis;
Amisulpride (↑ level of prolactine)
Aripiprazole (Abilify)
? depression ~
Atypical Neuroleptics

Common antipsychotic medication side effects
Dry mouth
Constipation
Blurred vision
Drowsiness

Serious antipsychotic medication side effects
Restlessness
Muscle stiffness
Slurred speech
Extremity tremors
Agranulocytosis

CRITERIA FOR THE QUALITY OF TREATMENT
Reduction of psychopathological symptoms for at least six months
Clinical
Social
and psychological
the capacity for autonomy and social functioning
Stability of mental state during not less than six months
+

Treatment
of schizophrenia
After treatment of acute schizophrenic psychosis long time maintain therapy:
after 1 episod – 2 years maintain therapy
after 2 episod – 5 years maintain therapy
- after 3 episod – 10 years maintain therapy

Schizophrenia-like psychotic disorder
Acute psychotic disorder in which the psychotic symptoms are relatively stable and meet the criteria of schizophrenia, but manifest during less than one month.

Treatment
During the transient psychotic states small doses of neuroleptics are prescribed (eg, haloperidol 2-5 mg / day), tranquilizers (eg, diazepam 2-10 mg / day).
For depressive states antidepressants are prescribed (eg, amitriptyline).
Social adaptation promotes individual and group psychotherapy.
To fix the acute condition of schizophrenia is used antipsychotic dose of drugs, equivalent to 300 – 800mg of chlorpromazine equivalents (t. E. 300-800 mg of chlorpromazine) per day.
Treatment of primary psychotic episode begins with atypical antipsychotics.
Typical antipsychotics do not remove negative symptoms and , on contrary, can aggravate it.
Atypical antipsychotics adjust negative symptoms.

Induced delusional disorder
A rare delusional disorder, which is shared by two or more people with close emotional contact.
Only one of the group suffering true psychotic disorder;
Delirium induced by other members of the group and is usually held in the separation;
Psychotic disease of the dominant person is often schizophrenic, but not always;
The original delusions in the dominant person and the induced delusions are usually chronic, and are content delusions of persecution or grandeur;
Delusional beliefs are transmitted only in special circumstances.

Delusional disorder
Every year there from 1 to 3 new cases of delusional disorders per 100 thousand population. This number is about 4% of all primary admissions to psychiatric hospitals among inorganic psychoses.
The average age of onset of the disease accounts for about 40 years, ranging from 25 to 90 years. The number of women with this type of disorder is slightly bigger than the number of men.

Delusional disorder
Situations that contribute to the development of delusional disorders:
1) subject of exaggerated expectation that he would meet the sadistic treatment;
2) situations which give rise to mistrust and suspicion;
3) social isolation;
4) a situation in which a growing sense of envy and jealousy;
5) a situation in which there is a decrease the level of self-esteem;
6) the situation that cause the subject to see their own shortcomings in others;
7) the situations in which enhanced the likelihood that the subject would be too much to reflect on the possible value of the events and motivations.

Classification of delirium
Primary
(Interpretative, primordial, verbal)
Secondary (sensual and imaginative)
Violation of thinking comes secondly after a interpretation of the delusional hallucinations, lack of reasoning, which are carried out in the form of insights that are vivid and emotionally rich.
The primary lesion in thinking - amazed rational, logical knowledge, distorted judgment, consistently supported by subjective evidence, having its own system. At the same time perception of the patient is not broken.

Delusional syndrome:
Paranoiac syndrome - a systematic interpretative delirium. Most monothematic. There has been no intellectual-mental easing.
Paranoid syndrome - unsystematic, typically in conjunction with hallucinations and other disorders.
Paraphrenic syndrome - a systematic, fantastic, coupled with hallucinations and psychic automatism.

Stages of development of delirium
Delusional mood - the belief that there were some changes somewhere (but is not yet known exactly where);
Delusional perception - in view of the growing anxiety appears delusional explanation of the meaning of individual phenomena;
Delusional interpretation - delusional explanation of all perceived phenomena;
Crystallization of delirium - the formation of finished delusions;
Attenuation of delirium - the emergence of criticism to the delusions;
Residual delusions are observed in hallucinatory-paranoid states, after the delirium and after the epileptic twilight state.

Paraphrenia
Greek.
Involutionary paraphrenia - represents delusional psychosis of elderly people, it is manifested by delusions of persecution and the impact (often with erotic content), mood swings, confabulations, and speech disorders.
Phren – mind, intelligence

The course and prognosis
The diagnosis of schizophenia can never be withdrawn, but a long-term compensation is possible.
• Under the influence of stress may arise decompensation
• In 30% of cases, the disease progresses slowly, and after many years, gradually reaches similarity with paranoid schizophrenia
• 10% of patients commit suicide attempts

Schizotypal disorder
Schizotypal disorder - a disorder is not suitable for diagnostic criteria of ICD-10 diagnosis of schizophrenia: there are no all the necessary symptoms or they are mild, erased.

Schizotypal disorder
In ukrainian psychiatry resemble the indolent (slow-) schizophrenia.
Diagnosis is complicated.
It is characterized by slow, long, mostly continuous flow.
There are two basic forms:
- Pseudoneurotic
- Pseudo psychopathic

The criteria according to ICD-10
A. For at least two years continuously or periodically be detected at least four of the following signs:
1) inappropriate or constricted affect, the patient looks cold and aloof;
2) strangeness, eccentricity, especially in behavior or appearance;
3) depletion of contacts and tendency to social autization;
4) strange looks (beliefs) or magical thinking, influencing behavior and inconsistent with the subcultural norms;
5) suspiciousness or paranoid ideas;
6) Obsessive ideas without inner resistance, often with dysmorphiaphobic, sexual or violent content;
7) unusual perceptual phenomena, including somatic-sensory (bodily) or other illusions, depersonalization and derealization;
8) amorphous, circumstantial, metaphorical, hyperdetailed and often stereotyped thinking, manifested by odd speech or in other ways without the expressed dissociation;
9) occasional transient quasi-psychotic episodes with intense illusions, auditory or other hallucinations and delusional ideas, usually occurring without external provocation.
B. The case should never meet the criteria for any disorder in schizophrenia F20- (schizophrenia).

Louis Wayne (1860-1939)
Creation of patients with schizophrenia

Mark Gudvolt
(1980)
Creation of patients with schizophrenia

Mark Gudvolt
(1980)
Arts of patients with schizophrenia

Salvador Felip Jacint Dalí Domenech Domenech and the Marquis de Pubol (1904 - 1989)
Spanish surrealist painter, graphic artist, sculptor, director, writer

Salvador Dali. Untitled. Dovetail and cello (a series of accidents), 1983 Last picture painted by the artist.

Francisco Jose de Goya
(1746 - 1828)
Self Portrait. Court painter of King of Spain, vice-director of the Royal Academy of Fine Arts of San Fernando

Friedrich Wilhelm Nietzsche
(1844 - 1900)
German philosopher

John Forbes Nash Jr
(1928 -)
American mathematician, Nobel Laureate in Economics 1994

Mikhail Vrubel
(1856 - 1910)
Self Portrait. Russian modernist painter

Franz Kafka
(1883 - 1924)
Austrian writer

Vincent Van Gogh
(1853 - 1890)
Self Portrait. Dutch postimpressionist painter

Emanuel Swedenborg
(1688 - 1772)
The Swedish natural scientist, theosophist, inventor. In 2004, the collection of manuscripts of the scientist was included in the Memory of the World Register

Ludwig II
(1845 - 1886)
The King of Bavaria

Victor Kandinsky
(1849 - 1889)
The Russian psychiatrist and author of "On pseudohallucinations"

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